ADD/ADHD in Four Parts: Part II: Making Sure It Really Is ADD

Florida Jewish News, October 14, 2005, pp. 15, 17

Just because you or someone you love has the symptoms described in Part I: The Rest of the Definition—even when a Psychologist, Neurologist, Psychiatrist, or other Mental Health professional agrees that you have them—is not sufficient to classify you as ADD. There are a number of other life circumstances that could bring on behaviors and states of mind that mimic the condition, so it is important to rule them out first.

(a) Abuse

I once attended a conference where I was amazed to see a video of a 5 year old child totally destroying his room over a three week period. He ripped wooden frames off windows and used the wood to beat family members who entered the room. He abused the dog. He would not let his parents come near him. He was in constant motion, aggressive, and seemed to be a sociopath in training. You might think he was ADHD among other things, but no, his behavior was the product of abuse and neglect by his birth mother followed by more of the same at the hands of his adoptive parents. This unloving, belligerent child is a typical and normal product of abuse. He was not ADHD.

This point is important to keep in mind if your own child acts like the above description. Could it be that a babysitter or other individual is mistreating your child? If you yourself sometimes fly into rages, could it be that you are suffering from untreated childhood abuse?

(b) Under-disciplining

At the other extreme from abusive parents are those who are afraid to discipline. These parents either were punished harshly themselves as children and have the concept of discipline confused with abuse or, they too, were overindulged. In either case, they did not teach their child limits and self control. Such a child could appear to be unable to listen, stay still, and concentrate when the problem is that he has merely never been required to. Parents who know how to discipline consistently combine their expectations with both external and internal consequences. Parents who want a given behavior but who don't know how to get it may be reduced to yelling, ignoring, or giving in. Before a professional can make a determination about ADD, parenting behavior must improve.

(c) Depression and stress

Whether there is a divorce, death, trauma, family violence, parental substance abuse, difficult peer relations, academic problems, absentee parents or any number of other stressors in a child's life, the resulting behavior can mimic ADD. Children with troubles on their minds may appear spacey when, in fact, their distracted behavior is perfectly understandable. How is the child supposed to learn when his mother is in the hospital? Or when he wonders whether the bully will tease him again at school?

Similarly, children with learning disabilities may blurt out anger or withdraw. Either could be a reaction to frustration with the subject rather than ADD. Let’s say a child is rather intelligent, is well-spoken, and does well in all subjects but one. It seems inconsistent that the child isn’t trying in just one subject, so the parent is perplexed. The child may tune out during that subject because paying attention has not helped. While this may seem like ADD behavior, academic testing may reveal a learning disability in the narrow confines of just that subject. On the flip side, gifted children may become irritable or withdrawn because they are bored in classrooms that do not challenge them. That behavior as well could be misdiagnosed as ADHD or ADD.

(d) Substance abuse

Depending on whether the drug of choice is an upper or downer, child substance abusers may behave as if they had attention deficit or hyperactivity or both. Drug use, drinking, and smoking frequently begin with children as young as 10, and depending on what is available at home, even younger. Of course, turning to substances is itself a symptom that something else has gone terribly wrong in that child's life. Substance abuse is not to be underestimated in the Jewish community, either. News items about this very topic have appeared in earlier editions of this newspaper—and they were just the ones that got into print.

(e) Lifestyle

Much has been written about the relationship between food additives and behavior as well as sugar and behavior. In a particular case, if all of the above, items a through d, have been ruled out, it seems only fair to children to assess the additive and sugar content of what they eat. In the same way, parents often fail to realize the importance of schedules. Children who are up too late at night may appear hyper and they will pay insufficient attention the next day. Eating dinner too late may cause difficulty sleeping. Young children exposed to gruesome shows on television have been repeatedly shown in research to exhibit trauma symptoms such as nightmares and preoccupation. And it doesn't take much to scare a child. The tough children who say it doesn't bother them are the ones who get the nightmares that rob them of restful sleep—and may not even remember why.

(f) Medical conditions

It is important to rule out medical conditions that could produce similar symptoms as those found in ADD such as hearing or vision impairment, thyroid disorder, vitamin deficiency, sleep apnea, or brain injury.

If all of the above have been clearly ruled out, please understand that, unlike testing for diabetes, one cannot draw blood to be certain of the diagnosis. Although there is some interesting work with CAT scans, there is none that can rule out or definitively determine the condition. At the November 16-18, 1998, the National Institutes of Health Consensus Conference on ADHD issued the following statement: “We do not have an independent, valid test for ADHD, and there are no data to indicate that ADHD is due to a brain malfunction” (p. 3).

Clinicians will agree that the final determination of the diagnosis is behavior. The most popular behavioral tool to make that final diagnosis is a simple paper and pencil test, The Connors Rating Scale, developed by C. Keith Connors, Ph.D., a psychologist who had been head of the Duke University ADHD Program at one time. The same test is available on computer for easy scoring.

Once a definitive diagnosis has been made, the question for parents is: Now what? The rest of this article and the next two issues address that.

Coping Begins with Proper Parenting

When an ADD/ADHD child is born into a family, the family is rarely ever prepared. But they better be or the child will soon run the house. What frequently happens is that parents who got away with very little discipline towards other children cannot understand why this one child will not listen or cooperate. The house turns into yelling matches, and soon, in the parent's heart, he or she starts to actually dislike that child. There could be an attempt at avoidance, certainly avoidance of confrontations, and that just makes things worse because eventually whatever the issue is must be addressed. Sure enough, there is the feared confrontation.

The solution is parent education in proper discipline. Studies show that ADD/ADHD children are more likely to be abused and/or neglected. There are a higher number of them represented in the adult criminal population. This is not the children's fault. It is the fault of improper discipline. So it is very important that the word "discipline" NOT be misinterpreted in such a way as to result in abuse. (If you are not clear where discipline ends and abuse begins, see a therapist because they are two entirely different things. Real discipline does NOT feel like punishment. It feels just and fair.)

The Genetic Complication

Most researchers think that ADD is genetic. The complication is that when a child exhibits ADHD behaviors such as impulsivity (making lightening-quick decisions which may be brilliant and creative—or not), it may trigger the parent’s own impulsive reaction of impatience. That may be because the child is challenging, but it also may be because an ADHD parent is unable to control his aggression. This indicates that the treatments must be addressed to the parents as well as the child.

Adult ADD

Children who have been diagnosed with ADD/ADHD will most likely continue with the same patterns as adults. Adults older than 30 may not be aware that they could be diagnosed with this “disorder” because it really didn’t become well known until the ’80s. However, it is estimated that 8 million adults have ADD. Although diagnosis has a negative component, namely, the attitude that there is something wrong with oneself because one has a “disorder,” there is also a downside for those adults who were never diagnosed—and there are many such individuals. That downside is that these adults may have had difficulties in school and later in life without knowing why. Thus, they pinned the blame on themselves and thought of themselves as failures. Putting a label on their difficulties enables such people to see their condition a little more objectively; there is some comfort in knowing that there are millions of comrades who share the problem.

Next issue: Part III: What You Need To Know About Medication